HESI 1 - V1 AND V2 EXAM STUDY GUIDE GRADED A+ WITH QUESTIONS AND CORRECT ANSWERS LATEST UPDATED VERSION 2026 - HEALTH ASSESSMENT 1

HESI 1 - V1 AND V2 EXAM STUDY GUIDE GRADED A+ WITH QUESTIONS AND CORRECT ANSWERS LATEST UPDATED VERSION 2026 - HEALTH ASSESSMENT 1 Which part of the body should the nurse examine when assessing for peripheral edema in a client with heart failure? - Answer ️Ankles. A client reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation? - Answer ️Use of vitamin and iron supplements. What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? - Answer ️Posterior chest below the 3rd intercostalspace. A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) - Answer ️Use simple sentences during the examination. Reduce environmental detractors during the examination. Ask questions one at a time to decrease confusion. The nurse is interviewing a client who reports having a persistent, productive cough during the winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis? - Answer ️Phlegm production and wheezing. The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? - Answer ️Press the tongue down one side at a time with a tongue depressor. The nurse is assessing a client who has a history of mitral stenosis. How should the nurse assess this client with a stethoscope to listen for this condition? - Answer ️Place the bell on the 5th intercostal space, left midclavicular line. Which statement is accurate about assessing the spleen? - Answer ️It must be enlarged at least three times normal size for it to be palpable. During an external examination of the eyes, the nurse gently palpates the eyes while the client's eyelids are closed. The eyes are both very firm and resist movement back into the orbit. How should the nurse document this finding? - Answer ️Abnormal finding. Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury? - Answer ️Glasgow Coma Scale. The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema. During the health assessment, the nurse should implement which technique to determine evidence of hepatomegaly? - Answer ️Use a bouncing motion to tap the middle finger placed within boundaries of the liver. What is the best nursing response to an older client who has not mentioned incontinence during a genitourinary assessment? - Answer ️Ask the client specifically about any leakage of urine. The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? - Answer ️The client is treating the nurse with respect. The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest? - Answer ️The left leg remains on the table *The Thomas test is performed by having the client bring one knee toward the chest while the other leg remains extended on the table. A positive Thomas test is elicited when the extended leg rises off the table when the opposite leg's knee is brought up to the client's chest, indicating hip flexor contracture. If the extended leg (the left leg, in this example) remains on the table, the test is negative. The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse place the stethoscope diaphragm to listen for this condition? - Answer ️2nd intercostal space along the right sternal border. The nurse is assessing a client who has experienced a sudden onset of hearing loss in the right ear. Which finding should alert the nurse to a potentially serious medical condition that requires further evaluation? - Answer ️There is no sign of associated infection. Which information should the nurse obtain to identify the client's self-perception of health status? - Answer ️Health history During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document? - Answer ️Cataracts. Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's lamp toexamine a client's skin lesions? - Answer ️Fungal infection. A client with dark skin is reporting a painful and itching area on the lower left leg. What should the nurse look for when assessing this client's skin for inflammation? - Answer ️Change in consistency. A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse anticipate hearing? - Answer ️Pleural friction rub A nurse is completing a nutritional assessment with a client. What is the easiest method for the nurse to use to get information about the client's nutritional intake? - Answer ️24-hour dietary recall The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) - Answer ️Diminished hair on legs. Skin cool to touch. The nurse is completing a physical assessment of a client who feel from a tree. The client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which assessment technique should the nurse implement when evaluating the client's spleen? - Answer ️Percuss the splenic area as the client takes a deep breath. The nurse enters an examination room to conduct a routine health assessment on an adolescent female client, who is accompanied by her mother. Which action by the nurse is likely to facilitate accurate responses to personal and social history questions? - Answer ️Request that the mother leave the exam room. While performing a mental status exam (MSE), the nurse asks a client to remember three unrelated words and repeat them later. The client was able to repeat the words as directed. Which computer documentation is accurate? - Answer ️"Short-term memory is intact." Which technique should the nurse implement when performing a Weber test? - Answer ️Place a vibrating tuning fork midline on top of the head Which technique should the nurse use to assess a client for scoliosis? - Answer ️Observe spine while the client is erect and bent forward Which term should the nurse use to document in the client's medical record for a high-pitched scratchy sound during auscultation of the heart? - Answer ️Friction rub While performing a head-to-toe assessment, the nurse assesses the client's pupillary accommodation. During the second portion of the test, the nurse notes that the client's pupils constrict and there is convergence of the axes of the eyes. What action should the nurse implement next? - Answer ️Document a normal finding. The nurse performs the Weber and Rinne tests to assess which cranial nerve? - Answer ️VIII - vestibulocochlear The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be able to visualize? - Answer ️Pharynx As a part of a routine health assessment, the nurse assesses the kidneys as part of the abdominal assessment. Which assessment finding should the nurse conclude is normal when palpating the client's right kidney? - Answer ️A round smooth mass that slides between the fingers. A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding indicates acute urinary retention? - Answer ️Dull sound percussed over bladder. *Clients with acute urinary retention may present with lower abdominal pain and bladder distension. Percussion (tapping on the body wall) is performed to detect differences in pitch. A dull sound produced when percussing a distended urinary bladder is an indication of urinary retention. The nurse examines the skin of an older adult client. Which skin variation is considered a normal finding for a client in this age group? - Answer ️Lentigines. *Lentigines or commonly referred to as liver spots are irregularly shaped dark spots on the skin caused by aging and extensive sun exposure. This skin variation is a normal finding in an older adult client. During a client's routine well-woman physical exam, the nurse examines the breasts. Which assessment technique should the nurse implement to evaluate for any abnormal lumps? - Answer ️With both arms at client's side, lift one arm and palpate the axilla. The nurse is completing a physical exam on an adult client. Which thyroid finding is considered normal? - Answer ️Gland is not palpable. How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart failure? - Answer ️Measure bilateral ankle circumference with a non-stretchable tape measure. A client has come to the clinic for a routine health assessment. What is the best assessment question for the nurse to ask a client after observing tophi on the client's ear cartilage? - Answer ️Have you had sudden and severe pain in the toes or feet?